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Virginia Do Not Resuscitate Form

The Virginia do not resuscitate form is provided by Virginia Department of Health.

Virginia Do Not Resuscitate Form
Authorized Durable Do Not Resuscitate Order Form & Instructions
Purpose
The Durable Do Not Resuscitate (DDNR) Order and its regulations have been developed to carry out the intent
of applicable Virginia law that provides a person the opportunity to execute a DDNR Order that comports with
his/her wishes.
Applicability
The DDNR form may be honored by any "qualified health care personnel," which is defined as any qualified
emergency medical services personnel and any licensed healthcare provider or practitioner functioning in any
facility, program or organization operated or licensed by the State Board of Health, or by the Department of
Mental Health, Mental Retardation and Substance Abuse Services or operated, licensed or owned by another
state agency, or a licensed health care practitioner at any continuing care retirement community.
Instructions
12VAC5-66-70. Issuance of a Durable DNR Order Form or Other DNR Order.
A Durable DNR Order Form or Other DNR Order may be issued to a patient by a physician, with whom the
patient has established a bona fide physician/patient relationship, only with the consent of the patient or, if the
patient is a minor or is otherwise incapable of making an informed decision regarding consent for such an order,
upon the request of and with the consent of the person authorized to consent on the patient's behalf.
1. The use of the Virginia Department of Health’s Office of Emergency Medical Services (VDH/OEMS)
authorized Durable DNR Order Form is encouraged to provide uniformity throughout the health care
continuum.
2. The authorized Durable DNR Order Form can be honored by qualified health care personnel in any
setting.
3. Patients that are not within a qualified health care facility or receiving hospice or health care services at
home must have an authorized Durable DNR Order Form (State Form) or alternate DDNR jewelry in
order for the DDNR Order to be honored.
4. Other DNR Orders can be honored any time when a patient is within a qualified health care facility,
during transfer between qualified health care facilities when the patient remains attended by qualified
health care personnel or receiving hospice or health care services at home.
5. The physician shall explain to the patient or the person authorized to consent on the patient's behalf, the
alternatives available for response in the event of cardiac or respiratory arrest. If the option of a Durable
DNR Order is agreed upon, the physician shall have the following responsibilities:
a. Explain when the Durable DNR Order can be followed.
b. Explain how to and who may revoke the Durable DNR.
c. Document the patient's full legal name.
d. Document the execution date of the Durable DNR Order.
e. Obtain the signature of the patient or the person authorized to consent on the patient's behalf on
all three forms; the patients copy, medical record copy, and the copy used for obtaining DNR
Jewelry.
Virginia Do Not Resuscitate Form
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